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ADHD: A Fair and Balanced View

OK, Dr. Gore, is it true that you know everything there is to know about Attention-Deficit/Hyperactivity Disorder? A: No.

Q: Then why should I ask you questions about Attention-Deficit/Hyperactivity Disorder?

A: Because I have some strong opinions about this “disorder.” And, because there is a lot of mis-information going around about this “disease.” And, I think some families would benefit if they thought differently about this “diagnosis.” And, I enjoy pissing off pharmaceutical companies, psychiatrists and pediatricians who over-diagnosis, mis-diagnosis and have no business “diagnosing” this “diagnosis.” And, it is your job to ask me questions.

Q: If Attention-Deficit/Hyperactivity Disorder (ADHD) is not a disorder or a disease, what is it, exactly?

A: It is a cluster of symptoms that, when taken as a whole, justify a diagnosis of ADHD. These symptoms include distractibility, impulsivity, hyperactivity, poor attentional skills AND there must be a BIOLOGICAL basis for the syndrome. Some children are distractible or impulsive or hyperactive because they are allowed to be. They are able to show better abilities with proper structure. If someone has a true ADHD, they cannot act any other way but distractible or impulsive or hyperactive, regardless of the rules, structure, rewards or punishment available. If someone has a true ADHD, then there is a biological (neurological) problem.

Q: Do you have scientific facts backing up your statements?

A: Yeah, I do. But, let’s just do this…DISCLAIMER: What you are about to read is merely one man’s opinion.

A: Historically, the “H” is ADHD represents “hyperactivity.” There have been attempts to show that ADD can exist without hyperactivity. At present, the accepted terminology is ADHD?

Q: Is there such a disease/disorder/syndrome/diagnosis as ADHD?

A: Yes, there is. However, it is fairly uncommon, and does not fit the classification of a disease or a disorder. ADHD is a description of symptoms. In my humble opinion, it impacts way less than one percent of the population.

Q: But I heard it affected five percent of girls, and up to twelve or fifteen percent of boys! And even the most conservative estimates suggest that at least three percent of the population is suffering from this disorder!

A: First off, stop using exclamation points! Just lob me questions. Second, where do you get those statistics?

Q: From unbiased sources, like Ciba-Geigy, the pharmaceutical company that manufactures Ritalin. Or, from Ch.A.D.D. (Children and Adults with Attention Deficit Disorders). Or, the American Psychiatric Association, the makers of the Diagnostic and Statistical Manual, Fifth Edition, the source of all mental health diagnoses.

A: I think these sources are all wrong. And, they are quite biased towards having as many people as possible suffer from this disease. Ch.A.D.D. gets a significant amount of its funding from the pharmaceutical industry. Ch.A.D.D. doesn’t think they are pro-pharmacology, but they are.

Q: Aren’t you “biased” as well?

A: Yes, I am biased towards helping children and families have kids who behave well, both at home and at school. And, I am biased towards achieving this goal without drugs or diagnosing. And, I am biased towards parents and schools not taking the easy way out by medicating children at the first sign of behavioral problems. And, I am biased because I feel that family therapy should be the first treatment offered.

Q: What about adult Attention-Deficit Hyperactivity Disorder?

A: That is a whole other topic. There are adults with the syndrome. They had it their whole lives. They could benefit from treatment. I just don’t believe that there are as many ADHD adults walking around as one would be led to believe. It is just not that common an occurrence.

A: Sure, about 75% of the time, they help kids and adults stay focused, and reduce excessive motor behavior. And, they do so rather quickly. And, they do so rather painlessly for the schoolteachers, parents, pediatricians and psychiatrists. Drugs work. Drugs work in reducing problems in the classroom, but will not make a child learn. I took speed in college, stayed up all night and wrote a paper due the next day. The speed “worked.” When I used to be tired in the morning, I drank two cups of strong coffee, and felt less tired. The caffeine “worked.”

There is a little-known study where professors took their normal, non-ADHD children and gave them performance tests (Dextroamphetamine: Cognitive and Behavioral Effects in Normal Prepubertal Boys. Judith L. Rapoport, Monte S. Buchsbaum, Theodore P. Zahn, Herbert Weingartner, Christy Ludlow and Edwin J. Mikkelsen. Science. Vol. 199, No. 4328, Feb. 3, 1978, pp. 560-563. American Association for the Advancement of Science.) Then they gave their kids speed, I mean, they gave their kids Ritalin. (Note: the professors did this to their own children because the government never would have allowed them to give the drugs to “normal” children, because giving speed to kids is not something the government condones.) Then, they retested their kids, and, lo and behold, the children’s test performances significantly improved!! I can use exclamation points!! The speed helped the normal children’s test scores and measures of attention.

Now, I know FAQ sections should have short, concise answers, but allow me one more paragraph, please. I know for a fact that for many years pediatricians were taught to “diagnosis” by giving Ritalin when ADHD is suspected, and, if behavior improves…then that CONFIRMS the diagnosis. Obviously, medical schools were not, and are not, aware that speed works. And it works on anybody, regardless of the presence or absence of ADHD.

3- There are other, less mild side effects: hypersensitivity, anorexia, palpitations, blood pressure and pulse changes, cardiac arrhythmia, anemia, scalp hair loss (no, I never took Ritalin), and toxic psychosis.

4- I might as well add that there is evidence (from sources where I was unable to evaluate the strength of their research) linking Ritalin and other stimulant medications prescribed for ADHD with: abnormal liver function, cerebral arteritis, leukopenia, and death. Now, I must admit to my readers, I have no idea what cerebral arteritis is, nor do I know what leukopenia is, but they both sound bad. And, of course, I can clearly state that “abnormal liver functioning” and “death” are not acceptable side effects in the pursuit of children behaving better and increasing SAT scores.

5- Giving pills to a kid sends them several important messages. A-You are not OK. B-You are lacking in something. C-Pills make you better and more whole. Note: I have heard at several Alcoholics Anonymous and Narcotics Anonymous meetings recovering alcoholics/addicts say something like, “The first time I knew that I needed to put some substance into my body to be ‘OK’ was when my doctor/teacher/father/mother told me to take Ritalin.”

6- More than nine out of ten children taking Ritalin, or another Stimulant Medication receive no therapy. They receive pills and that is all. Therapy can individually focus on giving a child some remediation strategies to help his or her behavior, to help his or her “focusing” behaviors, and to help him or her overcome the self-esteem issues that come with constantly getting trouble at school or home. More importantly, they are deprived of participating in family therapy, the single most powerful way to help with the syndrome of ADHD. Family therapy does not tell the child that he or she is not OK, it says that we as a group need to work on changing our behavior.

Q: Does family therapy really work?

A: Yes, it is as good as, and probably better than, any other treatment available.

Q: What happens in family therapy?

A: I believe that Mom and Dad (or just Dad, or just Mom) need to work on ways to make Junior behave/attend/focus better on tasks. I believe that if Junior learns better focus and attention at home, then this will translate to better focus and behavior at school.

Q: Is it that simple?

A: Yes.

Q: But I thought ADHD is an incredibly complex problem?

A: It is. But let us look at, finally, what ADHD truly is. There are some children, and adults, who have a neurologically-based impaired ability to focus attention on things for an extended period. Allow me to repeat, there is a neurological (a physical, a biological, a brain chemistry-based, etc.) deficit in the person’s nervous system. These people are few and far between.

Q: Say more, please…

A: These people, although they would still benefit from individual and family therapy, need some specific neurological help to better attend to tasks. These are the people that need Ritalin. But, most people on Ritalin are taking the drug because their behavior led to a mis-diagnosis.

Q: How do you know if the behavior is the problem, or if there is a neurologically-based problem with attention?

A: By getting a complete and thorough evaluation by a well-trained psychologist, examining the developmental and current aspects of the behaviors in multiple contexts.

Q: But aren’t most people given the diagnosis without any formal psychological testing?

A: Yes. And, that is the tragedy. That is why the rate of prescribing stimulant medication is steadily growing each year. Any why the rate of prescribing stimulant medication is extremely dependent on one’s geographical location and one’s socio-economic status.

Q: Gee, this is fascinating…say more, again…

A: There are some cities with a school district with one out of every three boys on some form of stimulant medication. Down the road, five miles away, only one out of forty boys are on some form of stimulant medication. Why? The first school district is in a wealthy part of town.

Q: So, wouldn’t these children have parents who are less likely to want their child on medication?

A: You would think that, wouldn’t you? But the opposite is often true, a “keep up with the Jones’s” mentality is in effect. You want your child to have good grades, and if they are not good, you will do anything to get the grades higher. Plus, there exists a herd mentality, if one child is getting the diagnosis, and getting drugs, and then getting better grades (and better behavior reports from the teacher), then that pediatrician will find his/her waiting room full of young people with the “disease” of ADHD.

Q: Is there some other geographical impact?

A: Yes, I think there is tremendous variation among towns and cities. I would take the unpopular position that Atlanta has one of the highest rates of kids on some form of stimulant medication, per square mile, in the United States.

Q: Wow. Speaking of the United States, what about in other parts of the world?

A: Funny you should ask that. This diagnosis is almost non-existent in many, many countries. Can you, dear readers, think of any disease that impacts as many as 15% of the male population of one and only one country? And, by the way, many of these countries (where ADHD is practically non-existent) have children that out-score American kids on different test measures, i.e., these are countries that also value their child’s education. But, as we speak, drug companies are out there trying to infiltrate the thinking of these countries’ physicians.

Q: Can we get back to the correct way to diagnose this problem?

A: Sure. First you go to a psychologist, or better yet, a neuropsychologist. Then you give them a check for at least eight hours of their time (between $800 and $4000.)

Q: Why would I pay that?

A: Because you want to make sure that your child actually has Attention-Deficit Hyperactivity Disorder, right? Or that you, as an adult, actually have ADHD.

Q: OK, just a little “sticker shock” there. Then what?

A: Well, here is what should happen: There should be a meeting with both parents and the child, to orient them both to the testing process. Then, the parent should be interviewed, and a history of the symptoms should be attained, including:

1-a medical history
2-a developmental history
3-a past psychiatric history
4-an educational history
5-a family history

Then the child should be interviewed, and depending on the age of the child, some of the same information should be sought…

Q: Wait a minute. How can a pediatrician do this, each visit to the pediatrician takes about fifteen minutes, at most? They don’t have time to do this…

A: Don’t interrupt me. Of course, they can’t do this, and, neither can most psychiatrists or family practice doctors. Most prescriptions for stimulant medications are based on a few minutes of complaints from parents, a cursory evaluation of school performance (maybe) and quick look at the offending child. Presto. Now, may I continue? You also want to get some pen and paper surveys filled out by the child’s teachers/nannies/day care providers/grandparents-anybody who spends time consistently with the child. This is done to assess the child’s behavior over several different settings. After interviewing the child, some formal testing should begin.

Q: Who is qualified to do this testing?

A: A licensed psychologist.

Q: What does this testing show?

A: First, overall intellectual skills are evaluated. Then, specifically, various measures of discrete types of intellectual skills are evaluated. The main source of the correct diagnosis of ADHD is in these discrete measures of intellectual performance. Some measures have little to do with attention, like understanding vocabulary words, or tests of abstract reasoning (“How are a cow and a monkey alike?” for example.) Others are directly influenced by attentional skills (“Say these numbers, in order, after me: 4, 8, 3, 5, 1, 6, and 2,” for example.)

Tests of academic achievement are also given. Further, memory tests are given, as well as specific measures of attention skills. Often, two or more testing sessions are required. Then the psychologist puts together all the information gathered into a report called a psychological evaluation. Then, there is a meeting where the child and parents are given the information discovered via the testing, this is called a feedback session. Now do you know why this takes at least eight hours? I don’t do these evaluations any more, they are too time consuming to do properly. Unfortunately, it is much easier for a physician to write a prescription than to undergo a thorough evaluation.

Q: What else can I get out of a psychological evaluation?

A: Most importantly, a correct diagnosis.

Q: I have heard of learning disabilities…Is there a pill that cures them?

A: No, but that doesn’t mean that a lot of kids on Ritalin do not have learning disabilities. A learning disability means that a child is of average, or above average intelligence and has a (neurologically-based) deficit in a discrete area of functioning. Most people think of dyslexia when thinking about learning disabilities (seeing letters or numbers reversed, like a ‘b’ is seen as a ‘d,’ is one form of dyslexia.) But one can have a learning disability in one of several areas, examples include in written expression, mathematics, language or reading.

Q: So, do you feel a lot of children diagnosed with ADHD are, in fact, learning disabled?

A: Yes, as many as 70% of children with the ADHD diagnosis have a learning disability. Now, you can be both ADHD and have a learning disability. But, most of the children I have seen who have been diagnosed with ADHD have neither ADHD nor a learning disability. These children are merely having behavioral problems. But, again, a full psychological evaluation is necessary to make sure there are not other issues (i.e., anxiety, depression, oppositionality/avoidance, etc.) that are presenting as ADHD.

Q: Isn’t there a simple test I can take that can give an appropriate diagnosis?

A: No

Q: I have a friend who took a computer-based continuous performance test. Their doctor said this was the only tool needed to diagnosis ADHD.

A: He’s an idiot.

Q: My friend?

A: No, the doctor.

Q: What about the Amen Clinic? They take brain scans and tell you what is wrong with your brain? And what about other brain scans?

A: The science is just not good enough (yet). SPECT scans, MRI’s, PET’s, fMRI’s…They don’t work as well as the sellers of these products say they do. I would call Amen an idiot, too, but he has a team of full-time lawyers who don’t like that. (My diagnosis: Napoleon Syndrome). So, I won’t.

Q: So, what is the best way to help these behavioral problems?

A: Family therapy.

Q: Why?

A: Parents are the people most likely to have the ability to correct a child’s behavior. They are, ideally, with the child a lot, and they have, ideally, a lot of power over the child.

Q: But what happens when parents feel that they have tried everything, and nothing has worked?

A: Family therapy will give the parents a lot more ways to help correct a child’s behavior.

Q: OK, so you like family therapy. What if my child actually has ADHD? What will family therapy do then?

A: Family therapy will do nothing to impact the neurological issues of attention difficulties…BUT, family therapy can still help with coping with the child’s behavior problems. And it can positively impact how the child approaches school.

Q: What about drugs?

A: If behavior change programs don’t work, then drugs are a reasonable next step. At least at this point the child and the parents know that every effort was attempted before drugs were introduced.

Q: If a child is on medication can family therapy still help?

A: Yes, medicine plus therapy can be a powerful combination. And, with good individual and family therapy, dosages can be cut back, and in some cases eliminated altogether.

Q: Doesn’t therapy take a lot of effort, time and money?

A: Yes, it isn’t easy. But, it is certainly better for the child, the parents and the whole family in the long run. Therapy is just not good for the drug companies.

Q: Do you want to give your disclaimer again?

A: Thanks. Good idea. The above are MY opinions, and nobody should take any actions without consulting their therapists, psychologists, or physicians. Reading this article is not a substitute for professional consultation. But don’t put your kid on medicine without a full psychological evaluation.